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“Having an abortion does not raise risk of mental health problems,” according to The Daily Telegraph. The newspaper says that “the world’s biggest review of the issue” has found that it makes no difference to a woman's mental health whether she chooses to have an abortion or continue with the pregnancy.

The extensive review behind this news analysed all relevant medical literature available on the matter to help understand whether women with an unwanted pregnancy who undergo an abortion (termination) are at greater risk of mental health problems than if they continue with the pregnancy. Its principle finding is that women who have an unwanted pregnancy are at no higher risk of adverse mental health effects if they have a termination compared to if they continue with the pregnancy. It also found that there were some specific factors associated with increased mental health problems following an abortion, including experiencing negative attitudes towards abortion and the experience of stressful personal circumstances.

The relationship between unwanted pregnancy, abortion or continued pregnancy and mental health are likely to be complex and not answered easily. The authors of this review also caution that there are unavoidable limitations to their analysis due to the variable quality and methods of the underlying research. However, this thorough analysis of the available literature would appear to indicate that for women who have an unwanted pregnancy, the risk of psychological effects is increased whether she chooses to continue with the pregnancy or not, and the researchers rightly call for all such women to have due care and support available to them, whatever their decision.

Where did the story come from?

This review, ‘Induced abortion and mental health’ was published by The National Collaborating Centre for Mental Health (NCCMH) and funded by the Department of Health.

The news reports generally give the overall message of this review. However, the headline of The Daily Telegraph – “Having an abortion does not raise risk of mental health problems” – is most accurate. The headlines of the Daily Mirror and The Independent, which say that abortion has “no effect” on mental health, could do with further clarity: women with an unwanted pregnancy who have an abortion are at risk of having adverse mental health effects, but this risk is no greater than if they continued with the pregnancy i.e. this mental health risk would appear to result from having an unwanted pregnancy, rather than the abortion itself.

What kind of research was this?

This was a systematic review that aimed to clarify the relationship between planned abortion (termination) and adverse mental health outcomes. The review was focusing upon women who have an abortion for the reason of unwanted pregnancy, rather than for health reasons relating to the mother or problems with the foetus. Related to this they aimed to address three specific questions:

How common are mental health problems in women who have an abortion?

What factors are associated with poor mental health outcomes following an abortion?

Are mental health problems more common in women who have an abortion for an unwanted pregnancy, when compared with women who deliver an unwanted pregnancy?

In the past there has been speculation over whether abortion itself may adversely affect a woman's mental health – despite the fact that many abortions in the UK are performed on the grounds that continuing with an unwanted pregnancy would risk psychological harm to the mother. In 2010 there were almost 190,000 abortions performed in England and Wales, and 98% of these were performed on the grounds that continuing with the pregnancy would risk physical or psychological harm to the woman or child. A third of these abortions were performed for a woman who had already had a previous abortion.

A systematic review is the best way to determine the overall body of evidence available on a particular question. A systematic review looks at the evidence of all relevant studies regardless of their findings, rather than selectively sampling those that support a particular view. Systematic reviews are regarded to be among the most robust sources of evidence.

What did the research involve?

This systematic review builds on the findings of previous systematic reviews, and has pooled the results of previous studies, where possible, into a single analysis (a meta-analysis). Multiple assessors examined the quality of the identified reviews and individual studies to ensure they were robust, and this was followed by a public consultation to obtain comments on the findings and discuss the content of the report.

Three prior systematic reviews were identified, two of which were qualitative (descriptive) reviews only with no quantitative pooling of results. They were:

The APA Task Force on Mental Health and Abortion (2008) systematic review, which included a broad range of studies of variable quality. These featured different periods of post-abortion follow-up, and aimed to address the mental health issues surrounding abortion.

A 2008 US systematic review by Charles and colleagues, which graded a range of relevant studies according to their quality and specifically looked at mental health problems in the longer term (occurring at least 90 days after the abortion).

A 2011 review by Coleman and colleagues, which performed a meta-analysis of the results of studies published between 1995 and 2009. It aimed to compare mental health outcomes for women who did and did not have an abortion.

The present review aimed to address the questions of:

Prevalence of mental health problems in women who have an abortion.

Factors associated with mental health problems in women who have an abortion.

The risks of mental health issues compared to continuing with an unwanted pregnancy.

Medical literature was searched to identify all English language studies published from 1990-2011 that looked at women who had a legal, planned abortion, and examined mental health outcomes occurring at least 90 days after abortion. Eligible studies had to have used validated diagnostic criteria to assess mental health outcomes; have assessed symptoms using validated rating scales; looked at the use of mental health treatments as an outcome; or looked at the outcomes of suicide or substance abuse. Studies had to have included at least 100 participants, and had as a comparison group, women who continued with their unwanted pregnancy. Where possible, meta-analysis was used to combine evidence from the comparative studies e.g. the odds of mental health problems if an abortion was performed compared to if it was not.

The reviewers found that the quality of the studies available varied, and that they had to take a pragmatic approach to decide which studies to include. Restricting the studies to those meeting the ideal quality thresholds would have meant that very few studies were included. For example, cohort studies would be the ideal type of study to assess the effect of abortion on mental health outcomes, but the review decided to also include cross-sectional studies, as long as they provided evidence that they were measuring post-abortion mental health, rather than mental health problems at any point in the women’s lives. The decision to exclude or include studies was based on their quality, and not the outcome of their results.

What were the basic results?

The review is extensive, therefore the findings are not reported in depth here. The main findings of the review group on consideration of the broad range of studies available and their limitations were that, on the best evidence available:

An unwanted pregnancy was associated with an increased risk of mental health problems.

For women with an unwanted pregnancy, the rates of mental health problems were the same whether they had an abortion or continued with the pregnancy.

The most reliable predictor of mental health problems after an abortion was having a history of mental health problems before the abortion i.e. those women that had experienced a mental health problem before their pregnancy were more likely to experience one afterwards.

The factors associated with increased rates of mental health problems were similar for women who had an abortion or who continued with the pregnancy.

There were, however, certain factors associated with higher risk of mental health problems that were specifically related to abortion. These included pressure from a partner to have an abortion; the experience of negative attitudes towards abortions in general; and the experience of negative views about the possible effects that having an abortion could have on a woman’s mental and emotional health.

The review group also made the following observations:

The rates of mental health problems after an abortion were higher when studies included women with prior mental health problems than in studies that had specifically excluded women with a history of mental health problems (i.e. indicating that prior mental health problems are a confounding factor in this relationships: prior mental health problems are likely to increase the risk of experiencing them after an abortion; it is not abortion itself that can be solely attributed to the outcome).

A negative emotional reaction immediately following an abortion may be an indicator of higher risk of continuing mental health problems.

Although they attempted to combine individual study findings in meta-analyses, they generally considered these pooled results to be of low quality, at significant risk of bias, and providing no greater insight into the issue compared to a well-conducted narrative review on the subject.

They considered that future research should focus on the mental health needs associated with an unwanted pregnancy, rather than the pregnancy outcome – abortion or continuation to birth.

How did the researchers interpret the results?

The review authors conclude that it is important to consider the support needs of a woman with an unwanted pregnancy, because there is a risk of subsequent mental health problems whatever the pregnancy outcome.

If a woman chooses an abortion, they advise that health and social care professionals are aware that she is more likely to be at risk of mental health problems if she has a history of prior mental health problems, has experienced negative attitudes towards abortion, has a negative emotional reaction to the abortion herself, or if she is experiencing stressful life events.

Conclusion

This is a thorough review that highlights that women with an unwanted pregnancy are at risk of adverse mental health effects, but that the decision to have an abortion or keep the pregnancy itself makes little difference to the risk of developing new mental health issues.

The authors acknowledge several important limitations to their review; principally that the included studies and reviews varied in design and quality. These included differences in terms of:

The mental health outcomes examined and how these were assessed.

Variations in the way adjustments were made to account for important confounding factors that might affect results (e.g. the presence of previous mental health problems, partner violence and abuse, etc).

The comparison groups they used; for example, some featured inappropriate comparisons, such as comparing women who had had an abortion with those who had given birth without considering whether or not the pregnancy was wanted.

Their reliance on analysing other sources of data such as national surveys and retrospective studies, which may be a source of some inaccuracy.

The authors also importantly note that some studies were conducted in countries where abortion is available on demand, whereas in other countries abortion was only carried out if it was definitely concluded that continuing with the pregnancy would risk the mental health of the mother. As such, the included study populations in different countries are likely to differ, and may not all reflect the UK situation.

Whether a woman considers her pregnancy ‘unwanted’ is also clearly a highly subjective feeling and will mean different things to different people. Furthermore, many factors are likely to influence the decision to continue with the pregnancy or not, such as emotional support from a partner, family or other social contacts.

The relationship between unwanted pregnancy, abortion or continued pregnancy and mental health is likely to be complex and not answered easily. However, as the review rightly concludes, for women who have an unwanted pregnancy, the risk of psychological effects is increased whatever the outcome – whether she chooses to continue with the pregnancy or not – and all such women require due care and support.